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Inside the  April 2009 print edition of Canadian Healthcare Technology:


VON to acquire electronic charting and other IT systems
The Victorian Order of Nurses, Canada’s largest home-nursing organization, has awarded a two-year contract worth more than $10 million to IBM Canada. Under the deal, IBM will completely computerize and re-engineer the way the agency works – from front-line nurses and home-care workers to back office planners.

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A new form of EHR
The Michener Institute, an educational and training centre in Toronto, has devised an Electronic Health Record system that’s aimed at groups, rather than individuals. The solution makes use of leading-edge technologies, such as giant screens and concurrent viewing of various diagnostic images.

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Minimizing medical error
A new book shows how organizations in the United States are innovating to reduce medical error. In some cases, high-tech systems are involved, but often, it’s a matter of administrative change.

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Northern Ontario uses innovative technology to create region-wide network
The North Eastern Ontario Network (NEON), consisting of 13 different healthcare organizations, has linked over 100 different clinical and business applications using the BizTalk Server integration engine from Microsoft.


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How to reduce DI wait times
Wait times for diagnostic imaging tests remain high across the country, with waits for CT and MR exams often averaging two or three times the provincial targets. We look at how a Nova Scotia hospital dramatically cut CT wait times.


Are wikis the way?
Wikis just might be the ultimate groupware, enabling any number of persons to apply their knowledge to a problem. Now, wikis are being used to solve the challenges faced by healthcare providers.


PLUS news stories, analysis, and features and more.

 

VON to acquire electronic charting and other IT systems

By Jerry Zeidenberg

OTTAWA – The Victorian Order of Nurses, Canada’s largest home-nursing organization, has awarded a two-year contract worth more than $10 million to IBM Canada. Under the deal, IBM will completely computerize and re-engineer the way the agency works – from front-line nurses and home-care workers to back office planners.

The project will include the acquisition and deployment of electronic patient record software, scheduling, financial and human resources systems, wireless and wired connectivity, and systems for the home monitoring of clients. The Victorian Order of Nurses, a not-for-profit organization, operates 52 locations across Canada and has nearly 13,000 staff and volunteers.

“The VON has been around for 112 years, and until now, we’ve done most things using pens, pencils and paper,” commented Dr. Judith Shamian, president and CEO. “We couldn’t see ourselves doing another 112 years this way. This is really about catching up with the 21st century.”

Interestingly, the VON hasn’t to date acquired an electronic medical record system. That’s something it will do as part of the two-year project with IBM. Advanced communication systems are also in the offing.

Dr. Shamian noted that the VON currently conducts an enormous amount of work – about 2 million home visits per year – that could be streamlined and made more efficient through the use of computerized and networked solutions.

Each day, the agency conducts thousands of nursing visits and receives referral documents that are 10 to 25 pages long – by fax. Those reports are processed, and then re-faxed. It’s a slow and painstaking process. “It’s also a poor use of the environment and resources,” commented Dr. Shamian.

Reports could be processed much more easily, accurately and quickly, using electronic technologies, she said.

Electronic solutions will also lead to more effective use of the agency’s human resources. For example, improved communication systems could alert a visiting nurse that one of her clients had an emergency and left for the hospital before a scheduled visit – thereby saving the nurse a good deal of time and trouble.

Dr. Shamian emphasized that the project isn’t simply a matter of installing various computerized technologies, but instead, it’s a re-engineering effort. “It’s not simply the purchase of systems,” she said, “it’s a change in the way we work.

“Technology without the right processes won’t solve the problems,” she observed.

As such, the VON is focusing on improving and streamlining its operations in three major areas.

First, its back office systems will be overhauled – there will be new scheduling, financial and HR systems put into place. This will help personnel at VON office better coordinate care.

Second, front-line care-givers. The way they work – and stay in touch with their offices – will be re-designed and enhanced.

“We’re assessing the use of smartphones, like BlackBerrys and notebook computers,” commented Barry Burk, vice president of healthcare solutions for IBM Canada. “But we’re trying not to let the technology take the lead. It’s the business process that will drive what they’re using, whether it’s a phone or a laptop. It will depend on the needs of the nurse or support worker.”

Third, the VON is seeking to build networked connections to the organizations that it works with – like health ministries and community care centres, as well as hospitals, pharmacies and physicians.

“It’s important for us to see what has happened to our client, Mrs. Smith, when she went to the hospital,” said Dr. Shamian. By the same token, “it would be useful for the caregivers in hospital to see a record of the care delivered to Mrs. Smith in her home in the previous six weeks.”

These links and systems will be constructed in each province, as the VON is a national organization. As such, the new system will need to mesh with various solutions used by partners in each jurisdiction.

However, Dr. Shamian says it will be important to coordinate what’s being developed, so that “14 different systems aren’t created in each province,” and that what’s used in one place is similar to that used in another.

She said the VON is very much in tune with the program of national standards that’s being orchestrated by Canada Health Infoway.

On the home care delivery front, the VON is planning to further develop remote monitoring solutions, which can alleviate shortages of skilled workers and keep costs in line, while improving the quality of care at the same time.

Dr. Shamian observed that such monitoring solutions could keep tabs on a client’s vital signs, alerting caregivers when a person is in distress or needs attention. “Remote solutions for chronic disease management are going to become very important,” she said. “We can monitor blood pressure, glucose and many other vital signs using remote systems.”

By using networked technologies, she added, care-givers and family members can keep close watch on patients and loved-ones with medical conditions – often bringing problems to the attention of experts before things take a turn for the worse.

“We need more of this,” she said. “It will be better for the patients and better for the system.”

The VON is already testing home monitoring systems, and it is also using systems that bring expertise to the home using telecommunications. One example is wound care, in which the visiting nurse can transmit pictures of a patient’s bedsores and wounds to an expert nurse or doctor at hospital, hundreds or thousands of miles away.

“Wound management is a very specialized field,” said Dr. Shamian. “There’s no way you can have an expert in every community. But you can take pictures with a digital camera and send them to an expert for advice, whether that person is in Halifax or Vancouver. You can then plan the next stage of treatment for the patient, right then and there.”

IBM’s Burk said more solutions of this kind are in the planning stages. “We want to do more analysis at the point-of-care,” he said. Having the right devices in the hands of nurses, along with the correct systems and training in place, will allow this kind of expertise to be brought to the home and the point-of-care.

The VON is also planning development of ‘smart home’ technologies, in which sensors are placed throughout the homes of patients. This will be particularly helpful for patients in the early stages of Alzheimer’s, who need help remembering to perform certain tasks. Sensors can also alert caregivers if the patient has fallen and can’t get up, or if his or her weight has dropped to an unhealthy level.

In this and many other areas, the VON will be looking to IBM and its business partners for solutions. “We’re trying to bring IBM’s brain power into this,” said Dr. Shamian.

Burk said IBM is contributing a wide-ranging perspective to the project, particularly in the area of business process re-design. “We’re not just bringing our experience in healthcare to the project, we’re going to bring in best practices from other industries, as well,” he said.

The move to re-engineer and computerize should help the VON cope with a rapid escalation in requests for home-care services.

Indeed, home healthcare is said to be the fastest-growing sector in healthcare and as the Canadian population ages, demand will increase. Approximately 900,000 Canadians regularly access home care. Between 1995 and 2002, the number of Canadians receiving home care increased by more than 60 percent.

Dr. Shamian commented that overhauling the way the VON does business is a major project, and will take longer than the two years allotted to the contract with IBM. In particular, she said, “We won’t have a complete EMR by that time – we’ll have to grow it over time.

Still, she is confident that a great deal will be accomplished in the next 24 months. “It will get us significantly along the way.”

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Michener Institute creates an advanced EHR, ideal for group work

By Jerry Zeidenberg

TORONTO – As part of its mission to build an innovative curriculum that’s supported by leading-edge technological solutions, The Michener Institute for Applied Health Science has devised an ‘EHR On-Demand’.

The new system utilizes emerging touchscreen technology on a 60-inch large-screen television, a $1,500 computer, and several client-based EHR platforms – including digital microscopy, a laboratory information system, a PACS, a radio-therapy information system, and an oncology treatment planning platform.

Together, the huge touchscreen and advanced software provide a new way of accessing and analyzing information, one that’s ideal for people working in groups.

Instead of using a keyboard to call up information on a small monitor, students and clinicians can use their fingers to launch images and move them around on the 60-inch screen. It’s a bit dazzling when you first see it – and almost magical.

Using the technology, several diagnostic images can be displayed at once on the same monitor – for example, CT slices and PET images, along with pathology images. Users can zoom in on an image just by pointing. They can move the images around the screen by ‘pulling’ on them, and they can merge them by stacking them on top of each other.

And a really futuristic touch – you can move a ‘ring’ over an image of the patient’s body, and slices will appear in different frames on-screen, showing CT or pathology images from that very region.

This form of accessing medical information has been demonstrated as work-in-progress by some healthcare IT vendors, but the application is now being used at the Michener. At the same time, the educational institute is developing new applications for the future.

Brad Niblett, chief information officer at the Michener Institute, said the EHR On-Demand unit improves inter-professional collaboration and provides students with a better way of learning as part of a healthcare team.

“Within our simulated clinical learning environments,” said Niblett, “we can support the information needs and workflow of the healthcare team by providing a dynamic, single point of access for patient-record information.

“The student healthcare team is empowered to create and launch specific EHR platforms as required,” he added. “They can also formulate their findings in a unique way through the power of the touch-screen technology.”

Dr. Karim Bandali, associate vice president of business development, noted the touchscreen technology, using a 60-inch plasma monitor, allows various clinical systems and diagnostic information to be displayed and positioned towards a group, or more specifically, the student healthcare team.

Moreover, “the real value with the current iteration of this touchscreen EHR is that the patient record becomes a fluid source of information, delivered, assessed and developed in an inter-professional experience, with the possibility of sharing this data live to a remote location for secondary consideration and/or diagnosis, or for educational experience,” said Dr. Bandali.

According to Dr. Paul Gamble, president and chief executive officer, the Michener’s latest technological solution represents another key milestone in an innovative curriculum that aims to move students seamlessly from the academic to the clinical setting.

“Our curriculum is one of the first in North America to leverage simulation-based technology in healthcare team settings to allow students from different medical professions to interact and to demonstrate leadership, conflict resolution and communication skills, all in a patient-centered care environment.”

Niblett added that, “this innovation, even in its current form, has significant implications for healthcare education and potentially the clinical environment.”

Jason Verbovszky, manager, information management, described the development process: “Our first set of ideas came from a demonstration of Google Earth within the touchscreen environment.

“We immediately thought, if adding the touchscreen enablers to an existing image-intensive application had such powerful transformative benefits, what would happen if we applied the same technology to diagnostic images of the human body? What would be the effect?”

The effect, he continued, was to utilize existing EHR platforms in fundamentally different ways to support the information needs of the healthcare team – all in a unique educational environment. “We’re hoping this will ultimately contribute to improved patient-centred care and safety.”

The team at the Michener Institute also thanked their collaborative partners in the innovative project. They include Relish Interactive, Elekta, CAE Inc., and Clear Canvas.

For an online video demonstration, visit www.youtube.com/watch?v=W7Jg9twIqto.

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How hospitals have transformed themselves to achieve higher quality

Transformative Quality: The Emerging Revolution in Health Care Performance
By Mark Hagland
Published 2009 by Productivity Press.
168 pages. (www.productivitypress.com)

Reviewed by Jerry Zeidenberg

In this new book, Mark Hagland, a veteran healthcare reporter based in Chicago, delves into the movement to reduce medical mistakes and improve the quality of care in U. S. hospitals. The core of the book revolves around fascinating profiles of organizations that have found new ways to cut back on the tragic deaths and injuries to patients that occur through preventable medical errors.

In the process, the hospitals have virtually transformed themselves – creating new models for the delivery of care.

Hagland emphasizes that top achievers have implemented ‘systemic’ change. Quality is not about individual improvements. Instead, it’s about whole teams of people changing the way they do things over a period of time.

While some changes involve sophisticated computerized technology, other solutions are much more simple – but equally effective.

A case in point is the Brigham and Women’s Hospital, a 747-bed behemoth in Boston. In 2001, the organization pioneered something called WalkRounds, in which top hospital executives conduct weekly visits to different areas of the hospital, accompanied by one or two nurses and other professionals. The group includes at least one hospital senior executive – either the CEO, COO, CMO, CNO or CIO. Together, they talk about adverse events and near misses, and what may have led to those events.

Top managers get a shop-floor view of what’s going on at the hospital, while front-line staff are shown that their concerns are of the utmost importance.

What type of issues come up, asks Hagland? There’s a broad range, from a door being open inappropriately to a nurse having trouble paging a physician.

WalkRounds takes place each week, every week. It’s followed by “a closed loop of analysis, discussion and further action.”

Of course, it’s critical to see hard numbers cited when trying to gauge performance, and most of the projects profiled in the book have tracked their work in this way. A nice example: On the pharmaceutical management front, an 18-month test program at seven San Francisco Bay-area hospitals improved medication administration accuracy from a baseline rate of 83.8 percent to 93 percent. Significantly, that figure of 93 percent made use of ‘shadow observers’ to document the accuracy of the nurses, rather than relying on self-reporting methods.

The six best-practices steps the nurses adhered to were:

• The nurse is required to compare a medication to the medical record for the patient to whom the medication will be administered.

• The nurse must not be distracted or interrupted from the time the medication is taken in hand until it is administered to the patient.

• The medication must be labeled from the time it is taken in hand to the time it is delivered to the patient.

• The nurse must check two forms of identification on the patient.

• When appropriate, the nurse must explain the medication to the patient at the time of administration.

• The nurse must document the administration of the medication to the patient in the chart immediately after it is administered.

Medication administration errors, notes Hagland, dropped by 57 percent during the course of the program. One might think that nurses would baulk at the extra work required; in reality, adherence to the six best practices increased to 92 percent by the end of the project, after starting out at 79.5 percent.

Perhaps the most unusual of the six steps is the notion of not interrupting the nurse as she or he administers medications. The hospitals derived this from the ‘sterile cockpit’ concept used in the aviation industry – when taking off, pilots are simply not interrupted, unless it’s an emergency.

Standardization of procedures in a hospital can dramatically increase patient safety and quality. That’s something the Pennsylvania-based Geisinger Health System found when it instilled standard practices in its cardiac surgery department.

The problem? Too much idiosyncrasy, as different surgeons used a variety of techniques and treatments. That was okay for the surgeons, but it would perplex the teams of allied professionals assisting them.

Geisinger broke down coronary artery bypass graft (CABG) operations into 41 separate steps. While national guidelines already existed for the procedure, they were very generic – like use antibiotics appropriately. Geisinger refined the guidelines, using evidence-based medicine from the literature, and made the steps much more specific.

Surgeons were allowed to opt out, if they chose; opt-outs would simply be reviewed by peers at a later date. As it turned out, only five opt-outs occurred from the time the program started in February 2006, to February 2008.

Meanwhile, in the first year of the CABG program, the patient mortality rate dropped to 0 from 1.5 percent. Pulmonary complications fell to 2.6 percent from 7.3 percent, and the average length of stay decreased by 16 percent.

In a review of this length, we can only scratch the surface of a book like Transformative Quality, and Hagland offers many more instructive examples.

By way of background, Hagland traces the impetus for much of today’s hospital quality movement to the 1999 release of the Institute of Medicine’s report, To Err is Human, which estimated that up 98,000 Americans die each year because of preventable medical errors. That many deaths is the equivalent of a jetliner crashing each day for a year and killing all of its passengers.

The report was like a slap in the face to doctors and hospital executives, along with healthcare associations and politicians. Since then, various programs have sprung up to improve patient safety, notably the Institute for Healthcare Improvement’s 100,000 Lives campaign.

Hagland points out that other factors have intervened since 1999. The press is now much more aware of the issue of medical error and has been regularly covering instances of foul-ups. It gave a great deal of news play in 2007 to the heparin overdosing of the twin infants of actor Dennis Quaid and his wife Kimberly Buffington. The newborns were accidentally given 10,000 units of the anti-coagulant instead of the required 10 units. Quick action saved the lives of the twins, but of course, there are many others who are not so fortunate.

Complicating the whole picture is the economic background. Demand for healthcare services has been rising and costs are exploding. Payers for healthcare services have decided they no longer want to pay for quantity – instead, they want quality.

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Canadian regions surge ahead with interoperable electronic health records

By Andy Shaw


Whether you call it an EMR, an EPR or an EHR, groups across Canada are trying to electronically bridge the islands of digital records that have sprung up in hospitals, long-term care centres, pharmacies and physician practices. The goal? To reap the enormous cost saving and superior patient outcomes that electronically shared health records promise. Among them, optimists say, up to 80 percent lower chronic disease costs, as well as dramatic reductions in redundant tests and medical errors.

None are working at this more keenly than innovators in Sudbury, Ontario, who serve the healthcare needs of over half a million residents in the province’s vast north-east. And they’re doing it through a shared services agreement among 13 healthcare organizations known as NEON, formally the North Eastern Ontario Network.

“We don’t think about ourselves very often this way, but our Dapasoft consultants and others have convinced me that we are out there on the leading edge,” says a modest Gaston Roy, NEON’s multi-hatted CIO.

Not to be outdone down in populous southern Ontario, Agfa HealthCare Inc., with headquarters in Toronto, is busy helping regional hospital groups to set world standards for health record interchange – rendering data “silos” into easily accessible repositories.

In the West, Alberta Netcare is building on the foundation of an already fully integrated electronic health record system – proven robust and scalable enough to serve an entire province, which was transformed overnight in 2008 by government decree into one giant health region.

Notable, too, for their yet again different approach are the xwave Healthcare-led or assisted consortia in British Columbia, New Brunswick, Nova Scotia, and Quebec. With varying scope, each consortium is making health records “interoperable” – capable of vaulting entrenched jurisdictional and technical barriers to information sharing.

Northern Ontario: Back in Northern Ontario, NEON and Gaston Roy’s IT staff of 56 are anchored in Sudbury, the region’s largest city. From there, working with the guidance of Dapasoft, a Toronto-based software development and systems consulting firm, they have built a record sharing system the world can envy.

“NEON really began as a Y2K exercise among eight hospitals back in 1998/99. Afterward, we went on to re-implement our Meditech clinical and financial systems to support the whole region,” says Roy. “But then we ran into some performance issues. And that’s where Dapasoft came in.”

With Dapasoft’s systems integration help, NEON now has a common IT infrastructure and a standardized Meditech information system that ties together two dozen, far-flung sites and 16 hospitals among them from its central host at the 527-bed Sudbury Regional Hospital (where Roy is employed as the CIO).

Live since last June, the novel data distribution network employs BizTalk Server 2006, Microsoft’s integration engine and Dapasoft’s Corolar interface software, to connect a plethora of applications and a multitude of systems. As a result, BizTalk can dish Meditech and other data to and from a regional PACS network, HIS, laboratory, WTIS (wait time information system), and EMPI (electronic master patient index) among others, including financial data.

Time was in Sudbury, and across Northern Ontario, if you ever used the word “interface” in polite conversation, people thought you were talking about some new mining technique to burrow out rock faces deep below in the Canadian Shield.

But today, above ground, creating interfaces is a primary mission of NEON and its caregivers.

“We have probably created over 100 interfaces and we’ve done that through BizTalk, which acts as a broker for those interfaces. Our programmers are very comfortable with BizTalk because they are used to working in (Microsoft’s) .Net. BizTalk takes feeds from the admission information at one hospital, for example, and distributes it to many other systems. So your connections with each other are no longer expensive point-to-point,” explains Roy. “Dapasoft helped us adapt BizTalk to the needs of the hospital world. And they also brought their Corolar product to bear, which expedites writing code for and thus creating those interfaces.”

For that ingenuity, Microsoft Canada honoured Dapasoft with its top business implementation award last year.

“I think, more than anything else, we won that award because of its impact,” says Dapasoft president Michael Lonsway. “What Microsoft was recognizing, particularly in light of the Canada Health Infoway blueprint for a pan-Canadian EHR, was just how significant the work was for successfully taking that integration and extending it beyond hospital walls.”

Gaston Roy has even more extensions in the works. “We’re just finalizing adding six more institutions to NEON this year and we’re continuing to develop more interfaces.”

Among them will be an interface for a higher level of wait-time programming, developed in co-operation with Dapasoft, which will improve the quality of data flowing into the Ontario wait-time system.

Regional healthcare providers are also confident they’ve got the tools to continue integrating various types of data, from different sources.

“We are now comfortable with sharing our information with other partners like the national HIAL (health information access layer) initiative in HL7 or XML or other standards,” says Roy. “But I think it is not so much the technology as it is our knowledge that will make us survive and grow.”

Southern Ontario: Agfa HealthCare sees itself growing by building what it views as the cornerstone of any electronic record system – readily accessible patient data repositories. Today, nine of 16 such repositories in Canada use Agfa’s technology.

Accessed through Agfa’s web-based Impax Clinical Dashboard viewer, the data centres allow different hospitals to view, enter, and share patient records. By signing on with Agfa recently as a shared services group, The Credit Valley, William Osler Health Centre, and Halton Healthcare Services hospitals in the Toronto area, and all six of their sites, in effect knocked down the information silos that kept them apart.

“If patients are getting examinations, tests, and other things done at different facilities as patients do these days, the challenge is to get all those records into one single view,” says Dave Wilson, Agfa’s vice-president for healthcare. “And if one record or part of that view is missing, then the physician can’t make a fully informed decision. But now, from every one of those three hospitals and their sites, a clinician can log in and see all of a patient’s records.”

Interestingly, the pundits often point out that European countries are way ahead of Canada when it comes to the electronic health record. But what’s remarkable about regions in Canada – such as Northern Ontario and also at Credit Valley, William Osler and Halton Healthcare – is that the electronic health records are interoperable. That’s quite rare, in North America, Europe and around the world.

“In those countries [like Denmark, Norway and Sweden], there’s a personal electronic health record now for every one of their citizens,” says Wilson. “While that’s admirable, those records by-and-large are still not shared much. So if your house straddles a boundary between two health regions in Sweden, for example, and if you injure yourself by falling out the back door instead of the front door, you might have to have a whole new hospital record made up for you.”

Similarly in the United Kingdom, adds Wilson. Even though the National Health Service (NHS) there is seeing to it that everyone in England will soon have an electronic record, the NHS hasn’t made much progress on having those records easily shared among regions.

“But here in Canada, we have,” says Wilson. “We are taking the so-called longitudinal view of the EHR. That means no matter where patients go, their past results can be compared to their current conditions.”

Agfa’s edge in enabling the longitudinal view of patient records stems from its nimble Enterprise Clinical Dashboard. As Wilson puts it, Dashboard users can “peer into the patient data repositories” at any time and pull out sought after data in real-time – regardless of what system produced them.

“In other words, hospitals that want to share data don’t need to be all on one Meditech or any other single information system,” says Wilson.

Naturally, being able to interface old legacy systems with new patient data repositories has a number of big advantages, including big savings.

“You don’t need any expensive ‘rip & tear’ of your current system. Also, training and learning curves are minimal, because you only need to learn one new system (Dashboard) which can access them all,” says Wilson.

Usage of the Dashboard makes healthcare delivery more accurate for physicians and nurses – because it gives them access to the patient’s records, no matter which hospital the patient last visited. That, of course, results in faster and higher-quality care.

It’s also more convenient for patients.

If we make health records shareable by virtue of making and storing them electronically, “then my Mother is going to be less insistent she always go to the Oshawa hospital rather than a more convenient one because, as she says, ‘Oshawa is where all my (paper) records are!’”

The work being done in Canada on interoperability of electronic records is no small achievement.

“We are very conscious that what we are developing here in Canada can be applied in the rest of the world, especially where there are public healthcare systems like ours,” says Wilson.

Systems refined in Canada may also appeal to the largely private healthcare system of the U.S., where local information sharing initiatives have started in the form of Regional Health Information Organizations (RHIOs). These efforts, which have stumbled in the last few years, will now be fuelled by President Barack Obama’s recent stimulus bill, in which US$2 billion was given to a federal organization charged with building networks and the standards they require.

It is this international potential for Canadian-developed health record and information sharing that has prompted the company to put up $170 million for Agfa HealthCare funded research and development centres in Waterloo and Toronto. The sum was topped up with another $29.6 million from the Province of Ontario – knowing there’s a market for electronic record keeping and other workflow improving systems in healthcare that’s worldwide.

If there are challenges ahead for the rest of the world, including Canada, in this drive to share records, they are likely to be not so much technical as human, thinks Wilson.

“Acceptance of any new system by people who use it, of course, is always a problem. And that is especially true of caregivers in healthcare. But it has been our experience in implementing change that those who complain about it most, at first, are often the ones to complain loudest if you try to take it away from them,” says Wilson. “If it is a good system, it becomes like my BlackBerry has become to me. You can’t live without it.”

That’s not to say that in all this record sharing there are not still technical gaps to close.

Says Wilson: “If we are truly going to have a longitudinal view of all our patients, then we’re going to have to include cardiac imaging and PACS records, which are not yet being shared nearly as much as they could be.”

Ironically, as Wilson points out, the digital revolution that has overtaken much of diagnostic imaging, can itself be a barrier to record sharing.

“Hospitals that have digitized and gone filmless often can’t share a record with another digitized hospital at all – because their computer systems can’t talk to each other.” What’s more, says Wilson, these filmless hospitals can no longer send each other a piece of film – something they could do in the past, even if it took days or weeks. Which means interoperability is urgently needed for the new, electronic systems.

Alberta: In the not so distant past, Alberta was made up of nine healthcare regions. No longer. In one fell swoop last spring, the Alberta government collapsed them into one. In the process, it took much of the complexity out of sharing Alberta health records, says Mark Bresson, an assistant deputy minister with the Alberta Health and Wellness ministry.

Bresson heads the ministry’s Information Strategic Services division and is therefore responsible for Netcare, Alberta’s initiative to build a single, province-wide EHR. In that position he sees strategic advantages stemming from last year’s dramatic consolidation.

“It has wiped out the duplication of effort and reduced the number of data repositories we’re going to need as Netcare evolves,” says Bresson, who holds a graduate degree in health information science.”

The data repositories currently in place are providing the province’s physicians with up-to-date, but essentially basic medical history data that’s helpful at the point of care.

“It’s been all about labs, drugs, DI, and text reports,” says Bresson. “But Netcare is not a project. It is a constantly evolving program. So now we are beginning to look at the ‘shared’ components of the health record that Canada Health Infoway would like to see in place and which go beyond the basic source systems we have working for us now.”

Bresson says his division is liaising with physicians and other providers to determine what other data sets exist in the office EMR that other clinicians treating the patient in other settings would like to see.

“It could be immunizations, or adverse reactions, or perhaps problem notes,” says Bresson. “But it would not be everything that a doctor’s EMR holds.”

Alberta Netcare is also evolving, reports Bresson, to much more sharing of records with patients. It now has a personal health portal under development.

“Right now our Netcare portal is a provider portal. If patients want to see their records, they have to be with the provider,” explains Bresson. “But our surveys tell us patients want to have better access to their health information and they want to manage that information.”

Bresson says the patient portal is still in the early stages, but expects that by the end of the 2009/2010 fiscal year decisions will have been made on the kind of data, the technology, and the security and privacy issues inherent in patient access.

Another project Alberta Health and Wellness has under way will facilitate that access to Netcare and its patient data repositories – moving further away from the nine-region complexity Alberta healthcare was and towards one-region simplicity.

“We’re pursuing a single sign-on for Netcare. So we are moving quickly with identity and access management software to that end,” says Bresson. “The single sign-on will allow us to move away from having so many security ID’s and passwords. That’s what we’re hearing from our users. They appreciated what has been built, so far, but the system is still too complicated to access.

Quebec, New Brunswick, Nova Scotia, British Columbia: It’s a firm belief on the part of those at xwave Healthcare that easy and widespread access to an electronic health record system is a question of what ‘level’ it sits at.

“We like the term ‘interoperable’ to describe what an electronic health record is. And to be interoperable, the EHR needs to sit outside of and above hospital or doctor office walls at what we call the ‘jurisdictional’ level,” says Nadeem Ahmed, the managing director and VP for xwave.

And xwave Healthcare, a division of Bell Aliant, is walking that talk as the project leader for provincial-wide implementations of an “I-EHR” for the entire provinces of Quebec and New Brunswick. xwave is also playing a supporting role in the implementation of similar I-EHRs in Nova Scotia and British Columbia.

But down at the clinical level, where doctors deal directly with patients, what difference does it make to have an I-EHR positioned much higher up?

“In the simplest of terms, today clinical decisions are being made with incomplete information,” replies Ahmed. “Today, physicians are treating patients with only the data they have in their own records or the data they are supplied with by an imperfect memory and understanding of the patient. So the purpose of the I-EHR, and these provincial projects, is to supply clinicians with all of the data that is available, so that the clinician can make a more effective diagnosis and treatment plan.”

But that’s not ultimately where these I-EHR implementations will lead, says xwave’s managing director and head of business development, Gary Folker.

“The least expensive members of the healthcare system are patients and their families. So if you can get data and information into their hands through the I-EHR, which helps them become their own caregivers, you can save the healthcare system enormous amounts of money,” says Folker. “It’s been estimated, for instance, that health records shared this way could reduce our chronic care expenses by 80 percent, and they account for 80 percent of our costs.”

Folker adds that xwave’s experience with electronic record sharing systems in four provinces points towards a more rational healthcare system. Electronic records in all their forms can help re-shape healthcare policy and capital investment, he thinks, because they supply better data of how many persons are sick where, with what – data that can be made available to decision makers.

“You can then ask questions like: Where are the greatest incidences of heart failure or lung cancer, and then decide where your cardiac hospitals or cancer clinics go.” That’s ultimately good for patients, and for the sustainability of Canada’s healthcare system.

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